University of Central Florida STARS Honors Undergraduate Theses UCF Theses and Dissertations 2020 Awareness of the Unaware: Anosognosia as a Comorbidity in Mental Health Conditions Tiffany L. Baula University of Central Florida Part of the Nursing Commons, and the Psychiatric and Mental Health Commons Find similar works at: https://stars.library.ucf.edu/honorstheses University of Central Florida Libraries http://library.ucf.edu This Open Access is brought to you for free and open access by the UCF Theses and Dissertations at STARS. It has been accepted for inclusion in Honors Undergraduate Theses by an authorized administrator of STARS. For more information, please contact [email protected]. Recommended Citation Baula, Tiffany L., "Awareness of the Unaware: Anosognosia as a Comorbidity in Mental Health Conditions" (2020). Honors Undergraduate Theses. 671. https://stars.library.ucf.edu/honorstheses/671 AWARENESS OF THE UNAWARE: ANSOGNOSIA AS A COMORBIDITY IN MENTAL HEALTH CONDITIONS by TIFFANY LAUREN BAULA A thesis submitted in partial fulfillment of the requirements for the Honors in the Major Program in Nursing in the College of Nursing and in the Burnett Honors College at the University of Central Florida Orlando, Florida Spring Term 2020 ABSTRACT AWARENESS OF THE UNAWARE: ANOSOGNOSIA AS A COMORBIDITY IN MENTAL HEALTH CONDITIONS Integrative Literature Review The primary purpose of this integrative review of the literature is to describe healthcare provider’s recognition of anosognosia in individuals with comorbid mental health disorders, as a differentiating diagnosis needing preeminent early intervention. The secondary purpose is to examine how anosognosia influences outcomes in the population of individuals with severe mental illness. It is expected that early recognition by clinicians and implementation of additional interventions to address anosognosia as the most influential comorbidity of schizophrenia, will decrease exacerbations and improve treatment and patient outcomes. A literature review exploring clinician’s acknowledgement of anosognosia was performed using various databases. Search terms included: Anosognosia, Lack of Insight, Denial of Illness, and Schizophrenia. The data was conformed into tables and synthesized the relationships to identify consistent findings as well as gaps in the current literature. Initial review of the articles retrieved 73 articles relevant to the topic and 18 articles that met inclusion criteria. The studies suggest that mental health conditions with anosognosia have increased rates of adverse outcomes. Anosognosia is a difficult disorder to identify. While many studies have explored the biological basis of anosognosia, the studies performed on safety with mental illness fail to acknowledge anosognosia as a co-morbid condition. Evaluation and clinical guidelines remain inconsistent with research to support the need for recognition of this co-morbidity. ii DEDICATIONS I would like to thank everyone in my life that has pushed me and been there to support me through my darkest times. To Dad, thank you for always motivating me to be the best version of myself, and raising me to always strive for something greater. I love you! You are my best friend, and my number one cheerleader, thank you for always being there for me. To Lorri, you are a truly amazing person, thank you for your love and encouragement and for bringing me into your family. And to my Nanny, without you I’m not sure how my life would have turned out. Thank you for giving me my childhood. Lastly, To my Mother, not a day goes by that I don’t miss you. Everything I do, is dedicated to you. iii TABLE OF CONTENTS INTRODUCTION ……………………………………………………………………………………………… 2 PROBLEMS TATEMENT …………………………………………………………………………………… 3 PURPOSE ……………………………………………………………………………………………………….. 6 BACKGROUND ……………………………………………………………………………………………….. 7 Assessment of Anosognosia ………………………………………………………………… 8 Theory of Organic Abnormalities as a Factor of Anosognosia ………………. 9 SIGNIFICANCE………………………………………………………………………………………………….. 12 METHODS ……………………………………………………………………………………………………….. 13 RESULTS …………………………………………………………………………………………………………. 15 Treatment Adherence and Insight ………………………………………………………… 15 Negative Outcomes ……………………………………………………………………………….. 17 Violence ……………………………………………………………………………………………….. 19 Suicide ………………………………………………………………………………………………… 20 DISCUSSION AND KNOWLEDGE GAPS ……………………………………………………………... 22 IMPLICATIONS ………………………………………………………………………………………………… 24 FIGURE 1: TABLE OF EVIDENCE …………………………………………………………….. 27 REFERENCES …………………………………………………………………………………………………… 44 INTRODUCTION Anosognosia, or the literal translation “Without Disease Knowledge”, has commonly been referred to as a lack of insight into one’s disease. Anosognosia has been recognized in a broad range of health conditions such as dementia, hemiplegia, and Huntington’s Disease, but is considered one of the cardinal clinical manifestations found in, 60-81% of all persons diagnosed with schizophrenia (World Health Organization, 2020). In individuals with schizophrenia, anosognosia is one of the most prevalent and influential attributes leading to adverse and inconsistent treatment outcomes of schizophrenia, including: Noncompliance to medication adherence, remission of psychological symptoms, impaired community function, risk of violence to self and others, and increased frequency of involuntary commitment to an acute mental health facility. In addition, the federal Healthcare Cost and Utilization Project, has found schizophrenia to be the third leading causes of hospital readmissions in the United States, only behind renal failure and ulcerative colitis (Fingar, K.R. et al., 2017). Anosognosia is a co-morbidity that carries heavy influence on the potential for positive outcomes in the treatment and management of schizophrenia, yet this complex construct has not been subjected to critical scrutiny or adequately addressed. Understanding the multifaceted phenomenon of anosognosia in the presence of related mental health conditions can improve the identification and treatment, and ultimate outcomes in quality of life, for people with anosognosia and co-morbid mental health conditions. 2 PROBLEM STATEMENT Psychiatric diagnoses are typically descriptive and are subject to scrutiny based on the clinical manifestations of the condition. There is currently no singular blood test or brain scan that can confidently diagnose a mental illness. Psychiatric mental health clinicians perform a series of exams and look to the DSM-V for diagnostic categories and dimensions as a pathway of assessment for underlying psychological conditions. Anosognosia is listed as an adjuvant clinical manifestations of schizophrenia in the DSM-V, however, at present time there is not a standardized diagnostic screening or plan of treatment for individuals with anosognosia as a comorbid condition with schizophrenia. This makes it exceedingly difficult to manage individuals that have disbelief in the accuracy of their diagnosis or the day-to-day consequence associated with their illness. The early detection of anosognosia and the pathological nature of the early stages of schizophrenia, are mainstay for reducing the duration of untreated psychosis. Reduction of the time an individual spends in a state of psychosis is exceptionally important because active psychosis is indicative of disease progression. Longer duration of untreated psychosis is associated with more severe symptoms when admitted to an acute care facility or mental health unit, poor prognosis, risk of violence, elevated risk for suicide, and more frequent relapses with involuntary commitment (Dell’Osso, Glick, Baldwin, & Altamura, 2013). At present time, reducing psychosis for the majority of individuals can only be achieved with consistent drug therapy adherence. The concept of insight into an individual’s mental health condition is the leading predictor of medication adherence, and primary reason for discontinuation of antipsychotic medication (Zhou, Rosenheck, Mohamed, 2017). When individuals do not have acceptance or acknowledgement of their illness, they are less likely to 3 seek out care or pay for drug therapy. Challenges in the care of a person with anosognosia and a combined mental health disorders occur when the individual’s preferences or beliefs, are at odds with the standard of care for their primary condition. Once correlations between anosognosia and poor treatment outcomes are established, clinician’s will be better prepared to implement additional interventions to guide treatment adherence and improved physiologic and psychological outcomes for this group of individuals. Anosognosia is a multifaceted phenomenon and planning for an appropriate treatment plan needs to take into account the individual's inability to recognize their illness, and failure to construct an adaptive narrative account of the challenges posed by having a psychiatric condition. An inability to reflect on the past and plan for the future makes the diagnosis of anosognosia in a mental health condition a key factor when determining treatment and drug therapy. Poor insight can directly influence difficulty in making sense of positive and negative clinical manifestations of psychiatric conditions (Osatuke, Ciesla, Kasckow, Zisook & Mohamed, 2008). For example, individuals with schizophrenia may have temporary delusions, however, individuals with schizophrenia and anosognosia are more likely to preserve positive symptoms as their reality, which can influence all decisions thereafter based off of